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F0684
D

Failure to Follow Physician's Order for Oxygen Administration

Weirton, West Virginia Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow a physician's order regarding the administration of oxygen therapy for a resident diagnosed with COPD. The physician's order specified that oxygen should be administered continuously at 2 liters per minute via nasal cannula. However, multiple observations revealed that the oxygen concentrator was set above the prescribed dosage on several occasions, including settings of 3.0 and 2.5 liters per minute. The discrepancy was identified during interviews and inspections, and it was only after being informed by surveyors that a registered nurse adjusted the concentrator to the correct setting. The resident was observed receiving oxygen therapy and reported feeling comfortable at the time, but the oxygen flow rate did not match the physician's order until after staff intervention prompted by surveyor notification.

See complete original report
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